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INTRODUCTION: The aim of this study is to share preliminary experiences and outcomes with a novel custom-made fenestrated TREO® Abdominal Stent-Graft System to treat juxtarenal and pararenal abdominal aortic aneurysms (AAAs). METHODS: Juxtarenal and pararenal AAA patients treated with the custom-made fenestrated TREO® Abdominal Stent-Graft System were included from 4 high-volume European academic medical centers from June 2021 to September 2023. Technical success and 30-day/in-hospital mortality and complications were analyzed. Technical success was defined as successful endovascular implantation of the stent graft with preservation of antegrade flow to the target vessels, and absence of type 1 or 2 endoleak (EL) at the first postoperative computed tomography angiography (CTA). RESULTS: Forty-two consecutive patients were included. The majority of the devices were constructed with 2 (N=4; 9.5%), 3 (N=9; 21.4%), or 4 (N=27; 64%) fenestrations. In 1 case, the device was constructed with a single fenestration (2.4%) and 1 device contained 5 fenestrations (2.4%); 17% had previous AAA repair. Target vessel cannulation with placement of a bridging stent was successful in all but 1 vessel (99, 3%). One aneurysm-related death occurred in the direct postoperative period and 2 limb occlusions necessitated reintervention during admission. In the median follow-up period of 101 (2-620) days, 3 more patients died due to non-aneurysm-related causes. Technical success was achieved in 90% of the cases. Nineteen ELs were seen on the first postoperative CT scan: 1 type 1b EL (N=1; 2%), 15 type 2 ELs (N=15; 36%), and 3 type 3 ELs (N=3%). Eleven patients received more than 1 CT scan during a median follow-up of 361 days (82-620): 3 type 2 ELs resolved and 1 type 3 EL was treated in this period. In the follow-up, 1 patient had a coagulation disorder that caused occlusions of the branches. CONCLUSION: The results of the first experiences using the custom-made fenestrated TREO® Abdominal Stent-Graft System in Europe are promising. There was a low short-term mortality and morbidity rate in these patients of which 17% had previous AAA repair. Mid-term and long-term follow-up data are needed to evaluate endograft durability and performance. CLINICAL IMPACT: This study shows the first experiences and short-term results of a novel low-profile custom-made device: the custom-made fenestrated TREO® Abdominal Stent-Graft System. Showing these results and experiences can help the physicians in clinical decision-making for their patients.
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INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for blunt thoracic aortic injury (BTAI) and has proven to be a good alternative to open surgery. TEVAR requires less operation time, has fewer complications, can be used for relatively unstable patients, and is associated with a significantly lower mortality rate. Moreover, long term follow up data demonstrate low re-intervention rates and stentgraft failure. REPORT: The case of a 21 year old man who sustained severe trauma, including a traumatic pseudoaneurysm of the descending thoracic aorta distal to the left subclavian artery in 2016, is presented. The patient was treated by TEVAR. Two years later, he presented with progressive paraplegia due to stentgraft occlusion occurring four days after a new high velocity motor vehicle accident. An axillofemoral bypass was performed to assure blood flow to the lower body. Two days later the stentgraft was removed via left thoracotomy and replaced by a Dacron graft. Gross examination showed severe thrombus formation at the proximal edge, and a thrombotic occlusion in the middle and distal third of the stent. After three months of hospitalisation the patient was discharged to a rehabilitation clinic with partial recovery of his paraplegia. As of June 2020, the patient was able to walk without assistance and his paraplegia improved with only loss of sensation of his lower legs. CONCLUSION: A serious thrombotic complication two years after TEVAR is described. Although TEVAR is the currently preferred treatment for BTAI, more research is needed to examine the mechanisms behind this thrombotic complication and to elucidate whether TEVAR is definitive treatment or a "bridge to further surgery". Smaller diameter stentgrafts, anticoagulation, regular (lifelong) follow up imaging, and prophylactic surgical conversion in (selected) patients might help to prevent this serious complication.
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OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively). CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.
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Aneurisma Ilíaco/cirugía , Anciano , Anciano de 80 o más Años , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/mortalidad , Procedimientos Endovasculares/estadística & datos numéricos , Femenino , Adhesión a Directriz/estadística & datos numéricos , Humanos , Aneurisma Ilíaco/epidemiología , Aneurisma Ilíaco/mortalidad , Aneurisma Ilíaco/patología , Arteria Ilíaca/patología , Arteria Ilíaca/cirugía , Masculino , Países Bajos/epidemiología , Sistema de Registros , Estudios Retrospectivos , Factores Sexuales , Resultado del TratamientoRESUMEN
OBJECTIVES: To investigate whether a fixed heparin dose results in adequate heparinisation levels and consequent inhibition of haemostatic activation in all patients. METHODS: This prospective clinical pilot study included 24 patients undergoing arterial vascular surgery. Individual heparin responsiveness was assessed using the Heparin Dose Response (HDR) test, while the activated clotting time (ACT) and heparin concentration were measured to monitor the peri-procedural degree of anticoagulation. Finally, peri-operative haemostasis was evaluated with rotational thromboelastometry (ROTEM). RESULTS: Eight patients were identified with reduced heparin sensitivity (RS group) and 16 patients with normal heparin sensitivity (NS group). Compared with the NS group, the RS group showed less prolonged ACTs after heparinisation with heparin concentrations below the calculated target heparin concentration. ROTEM revealed shorter clot formation times in the intrinsically activated coagulation test (INTEM) 3 min (114 ± 48 s vs. 210 ± 128 s) and 30 min after the initial heparin bolus (103 ± 48 s vs. 173 ± 81 s) in the RS group compared with the NS group. In the RS group, one patient developed a major thromboembolic complication. CONCLUSIONS: This study shows that a third of the study population had reduced heparin sensitivity, which was associated with lower levels of heparinisation, and lower inhibition levels of clot initiation and clot formation. Identifying patients with reduced heparin sensitivity by monitoring the anticoagulant effect of heparin could decrease the risk of thrombotic complications after arterial vascular surgery.
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Anticoagulantes/farmacología , Coagulación Sanguínea/efectos de los fármacos , Heparina/farmacología , Procedimientos Quirúrgicos Vasculares , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , TromboelastografíaRESUMEN
OBJECTIVES: To determine the influence of a positive family history for aneurysms on clinical success and mortality after endovascular aneurysm repair (EVAR). METHODS: From 2009 to 2011, 1262 patients with abdominal aortic aneurysms (AAA) treated by EVAR were enrolled in a prospective, industry sponsored clinical registry ENGAGE. Patients were classified into familial and sporadic AAA patients according to baseline clinical reports. Clinical characteristics, aneurysm morphology, and follow-up were registered. The primary endpoint was clinical success after EVAR, a composite of technical success and freedom from the following complications: AAA increase >5 mm, type I and III endoleak, rupture, conversion, secondary procedures, migration, and occlusion. Secondary endpoints were the individual components of clinical success, 30 day mortality, and aneurysm related and all cause mortality. RESULTS: Of the 1262 AAA patients (89.5% male and mean age 73.1 years), 86 patients (6.8%) reported a positive family history and were classified as familial AAA. Duration of follow-up was 4.4 ± 1.7 years. Patients with familial AAA were more often female (18.6% vs. 9.9%, p = .012). No difference was observed in aneurysm morphology. There was no significant difference in clinical success between patients with familial and sporadic AAA (72.1% vs. 79.3%, p=.116). Familial AAA patients had a higher 30 day mortality after EVAR (4.7% vs. 1.0%, adjusted HR 5.7, 1.8-17.9, p = .003) as well as aneurysm related mortality (5.8% vs. 1.3%, adjusted HR 5.4, 1.9-14.9, p = .001), while no difference was observed in all cause mortality (19.8% vs. 24.3%, adjusted HR 0.8, 0.5-1.4, p = .501). CONCLUSIONS: The current study shows a higher 30 day mortality after EVAR in familial AAA patients. Future studies should determine the role of family history in AAA treatment, suitability for endovascular or open repair, and on adaptation of post-operative surveillance. For the time being, patients with familial forms of AAA should be considered at higher risk for EVAR and warrant extra vigilance.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/mortalidad , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/genética , Aneurisma de la Aorta Abdominal/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Europa (Continente) , Femenino , Predisposición Genética a la Enfermedad , Humanos , Estimación de Kaplan-Meier , Masculino , Análisis Multivariante , Oportunidad Relativa , Fenotipo , Complicaciones Posoperatorias/mortalidad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Sistema de Registros , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The erosion of the early mortality advantage of elective endovascular aneurysm repair (EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation. METHODS: An individual-patient data meta-analysis of four multicentre randomized trials of EVAR versus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention. RESULTS: The analysis included 2783 patients, with 14 245 person-years of follow-up (median 5·5 years). Early (0-6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89; P = 0·010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89; P = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0·022) in the period from 6 months to 4 years after randomization. CONCLUSION: The early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anévrysme de l'aorte abdominale, Chirurgie versus Endoprothèse), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575.
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Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Quirúrgicos Electivos/métodos , Procedimientos Endovasculares , Injerto Vascular/métodos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Reoperación , Resultado del TratamientoRESUMEN
BACKGROUND: Long-term survival is similar after open or endovascular repair of abdominal aortic aneurysm. Few data exist on the effect of either procedure on long-term health-related quality of life (HRQoL) and health status. METHODS: Patients enrolled in a multicentre randomized clinical trial (DREAM trial; 2000-2003) in Europe of open repair versus endovascular repair (EVAR) of abdominal aortic aneurysm were asked to complete questionnaires on health status and HRQoL. HRQoL scores were assessed at baseline and at 13 time points thereafter, using generic tools, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36®) and EuroQol 5D (EQ-5D™). Physical (PCS) and mental component summary scores were also calculated. Follow-up was 5 years. RESULTS: Some 332 of 351 patients enrolled in the trial returned questionnaires. More than 70 per cent of questionnaires were returned at each time point. Both surgical interventions had a short-term negative effect on HRQoL and health status. This was less severe in the EVAR group than in the open repair group. In the longer term the physical domains of SF-36® favoured open repair: mean difference in PCS score between open repair and EVAR -1·98 (95 per cent c.i. -3·56 to -0·41). EQ-5D™ descriptive and EQ-5D™ visual analogue scale scores for open repair were also superior to those for EVAR after the initial 6-week interval: mean difference -0·06 (-0·10 to -0·02) and -4·09 (-6·91 to -1·27) respectively. CONCLUSION: In this study EVAR appeared to be associated with less severe disruption to HRQoL and health status in the short term. However, during longer-term follow-up to 5 years, patients receiving open repair appeared to have improved quality of life and health status.
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Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares , Calidad de Vida , Anciano , Bélgica , Femenino , Estudios de Seguimiento , Estado de Salud , Humanos , Masculino , Países Bajos , Encuestas y Cuestionarios , Escala Visual AnalógicaRESUMEN
OBJECTIVE: (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) scanning has been suggested as a means to detect vascular graft infections. However, little is known about the typical FDG uptake patterns associated with synthetic vascular graft implantation. The aim of the present study was to compare uninfected and infected central vascular grafts in terms of various parameters used to interpret PET images. METHODS: From 2007 through 2013, patients in whom a FDG-PET scan was performed for any indication after open or endovascular central arterial prosthetic reconstruction were identified. Graft infection was defined as the presence of clinical or biochemical signs of graft infection with positive cultures or based on a combination of clinical, biochemical, and imaging parameters (other than PET scan data). All other grafts were deemed uninfected. PET images were analyzed using maximum systemic uptake value (SUVmax), tissue to background ratio (TBR), visual grading scale (VGS), and focality of FDG uptake (focal or homogenous). RESULTS: Twenty-seven uninfected and 32 infected grafts were identified. Median SUVmax was 3.3 (interquartile range [IQR] 2.0-4.2) for the uninfected grafts and 5.7 for the infected grafts (IQR 2.2-7.8). Mean TBR was 2.0 (IQR 1.4-2.5) and 3.2 (IQR 1.5-3.5), respectively. On VGS, 44% of the uninfected and 72% of the infected grafts were judged as a high probability for infection. Homogenous FDG uptake was noted in 74% of the uninfected and 31% of the infected grafts. Uptake patterns of uninfected and infected grafts showed a large overlap for all parameters. CONCLUSION: The patterns of FDG uptake for uninfected vascular grafts largely overlap with those of infected vascular grafts. This questions the value of these individual FDG-PET-CT parameters in identifying infected grafts.
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Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular/efectos adversos , Fluorodesoxiglucosa F18 , Tomografía de Emisión de Positrones , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Radiofármacos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Diseño de Prótesis , Infecciones Relacionadas con Prótesis/etiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: The introduction of endovascular techniques has had a major impact on the case mix of patients that undergo open aortic reconstruction. Hypothetically, this may also have increased the incidence of aortic graft infection (AGI). The aim of this study was to report on the short and mid-term incidence of AGI after primary open prosthetic aortic reconstruction in the endovascular era. METHODS: From 2000 to 2010, all 514 patients in a tertiary referral university hospital, undergoing primary open prosthetic aortic reconstruction for aneurysmal or occlusive aortic disease with at least one aortic anastomosis were included. Data were obtained by retrospectively analyzing the medical records, by contacting patients or their general practitioner by telephone, and by merging the dataset with the national Cause of Death Register. AGI was defined as proven by cultures or clinically in combination with positive imaging results. The 30 day, 1 year, and 2 year incidence rates were computed using life table analysis and expressed as percentages with 95% confidence intervals (CI). RESULTS: AGI was diagnosed in 23 of the 514 included patients. 56% of the patients underwent elective surgery and 86% underwent surgery for an abdominal aortic aneurysm. The 30 day incidence was 1.6% (95% CI 0.4-2.8%), 1 year incidence was 3.6% (95% CI 1.7-5.5%), and 2 year incidence for AGI was 4.5% (95% CI 2.4-6.6%). The total number of person years (1058) yielded an AGI rate of 2.2 per 100 person years. CONCLUSION: The 2 year cumulative incidence of AGI following primary, open aortic procedures with at least one aortic anastomosis is considerable, at around 1 in 20.
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Aneurisma de la Aorta Abdominal/cirugía , Procedimientos de Cirugía Plástica/efectos adversos , Infección de la Herida Quirúrgica/etiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Infección de la Herida Quirúrgica/epidemiología , Resultado del TratamientoRESUMEN
BACKGROUND: Deterioration of renal function after major vascular surgery is an important complication, and may vary between patients undergoing endovascular (EVAR) or open surgical (OR) repair of an abdominal aortic aneurysm (AAA). The objective was to determine the impact of OR and EVAR on renal function after 5 years. METHODS: This was a post hoc analysis of data collected prospectively from the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial. Five years after surgery, creatinine levels were available for 189 patients (94 after OR and 95 after EVAR). The severity of renal disease was staged using the chronic kidney disease classification of the US National Kidney Foundation clinical guidelines. RESULTS: Using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, the estimated glomerular filtration rate (eGFR) for the entire group declined over time, with a mean(s.d.) preoperative value of 80·0(7·6) ml per min per 1·73 m(2) compared with 75·7(9·7) ml per min per 1·73 m(2) after 5 years (mean difference 4·2 (95 per cent confidence interval 3·2 to 5·3) ml per min per 1·73 m(2) ; P < 0·001). Five years after surgery, the mean eGFR (CKD-EPI equation) was not significantly different between the OR and EVAR groups: 76·3(9·3) versus 75·1(10·0) ml per min per 1·73 m(2) (mean difference 1·2 (-1·6 to 3·9) ml per min per 1·73 m(2) ; P = 0·410). CONCLUSION: Renal function 5 years after OR and EVAR for AAA was similar. Neither surgical procedure accelerated the loss of renal function.
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Aneurisma de la Aorta Abdominal/cirugía , Tasa de Filtración Glomerular/fisiología , Complicaciones Posoperatorias/fisiopatología , Insuficiencia Renal Crónica/fisiopatología , Anciano , Aneurisma de la Aorta Abdominal/fisiopatología , Procedimientos Endovasculares , Femenino , Estudios de Seguimiento , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Insuficiencia Renal Crónica/etiologíaRESUMEN
With data from four randomized trials on elective endovascular abdominal aortic aneurysm repair and many more additional post-hoc publications, the evidence can be somewhat overwhelming for the surgeon, let alone the patient. This chapter aims to present the most recent and relevant data for decision making in abdominal aortic aneurysm (AAA) repair in a comparative and concise format. After a comparison of the short- and long-term survival data of the randomized trials, the following post-hoc analyses of the four randomized trials will be presented: causes of death, reinterventions, renal function, prediction of complications, and quality of life. When both open and endovascular repair are a reasonable option for an individual patient, we need to objectively inform our patient about the available evidence from the trials. The three-fold reduction of operative mortality with endovascular repair as compared to open repair should be presented. Next, the convergence of the overall survival curves should be discussed as a key factor in the decision process. The counterintuitive observation may be considered that if endovascular repair is better for any specific subgroup it is for younger patients with low surgical risks. Finally, the patient needs to understand that the risks of reintervention and complications are higher after endovascular than after open repair and that this is even more relevant in older patients with larger aneurysms. The information that the quality of life advantage of endovascular repair is only short lived and for several domains surpassed by open repair is most likely not suitable for direct discussion with the individual patient, but it may put the procedures in the right perspective for the physician and health care managers.
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Aneurisma de la Aorta Abdominal/cirugía , Toma de Decisiones , Procedimientos Quirúrgicos Vasculares/métodos , Procedimientos Endovasculares/métodos , Humanos , Resultado del TratamientoRESUMEN
BACKGROUND: The effectiveness of open and endovascular aneurysm repair of aortic abdominal aneurysms (AAAs) can be jeopardised by deterioration of the residual infrarenal neck of the aneurysm. OBJECTIVE: The study aims to determine the length of the residual infrarenal aortic segment after endovascular and open aneurysm repair. METHODS: In a multicentre randomised controlled trial comparing open and endovascular AAA repair, 165 patients were discharged after open AAA repair (OR) and 169 after endovascular repair (EVAR). Immediately after the operation, surgeons were asked to enter in the case record form whether the level of their anastomosis after open repair was within or beyond 10 mm of the caudal renal artery. Postoperative computed tomography (CT) scans that were obtained within 6 months after surgery were used for comparative analysis. The distance between the caudal renal artery and the proximal anastomosis of the (endo-) graft was measured using axial CT slices and a standardised protocol. CT images were available and suitable for analysis in 156 (95%) of 165 OR patients and in 160 (95%) of 169 EVAR patients. Data are presented as median (range). Differences were analysed using the Mann-Whitney test. RESULTS: The distance from the caudal renal artery to the proximal anastomosis was 24 mm (16-30 mm) in the OR group versus 0 mm (0-6 mm) in the EVAR group (p < 0.0001, Mann-Whitney). In 140 of 156 (90%) patients, at least 1 cm of untreated infrarenal neck persisted after OR and in 17 of 160 (10%) after EVAR. In 84 of the 156 open repair patients (54%), the surgeon had indicated that the proximal anastomosis was within 10 mm of the caudal renal artery. Only five surgeons (6%) were accurate in this respect. CONCLUSION: After open repair, a longer segment of the infrarenal aortic neck is left untreated compared with endovascular repair and this length is underestimated by most surgeons. Long-term studies are required to determine the consequences of this difference.
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Aneurisma de la Aorta Abdominal/cirugía , Anciano , Aneurisma de la Aorta Abdominal/patología , Procedimientos Endovasculares/métodos , Femenino , Humanos , Masculino , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
AIM: Endovascular skills are an integral part of modern-day vascular surgery. The STRESS machine has been developed to test these skills in vascular surgeons. This study aims to define an optimal pass/fail cutoff value for the STRESS test score. METHODS: The STRESS machine consists of a dry glass model of the abdominal aorta and its tributaries with various stenotic lesions, elongations, and tortuosities. A camera and computer software are used to simulate plain fluoroscopy-mode. The test subjects are given two assignments after which two reviewers use a combination of the ICEPS and MRS to produce the final total score; 43 subjects were tested. According to previous endovascular experience, subjects were classified into four groups: novice-low (no experience, less than 11 performed procedures, less than 50 assisted procedures), novice-high (11-25 performed procedures, more than 50 assisted procedures), intermediate (1-10 performed and >11-25 assisted procedures, 11-25 performed and >1-10 assisted procedures or 25-50 performed procedures) and advanced (more than 50 performed procedures). RESULTS: Test-score and noted experience showed a correlation of 0.794. All intermediate and advanced test subjects scored more than 50 points compared to 4 out of 15 novices. CONCLUSION: We demonstrated that it is possible to determine an optimal cut-off value for competence testing with the STRESS machine.
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Aorta Abdominal/cirugía , Enfermedades de la Aorta/cirugía , Competencia Clínica , Simulación por Computador , Destreza Motora , Evaluación de Resultado en la Atención de Salud , Procedimientos Quirúrgicos Vasculares , Aorta Abdominal/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Humanos , Radiografía , Reproducibilidad de los Resultados , Análisis y Desempeño de TareasRESUMEN
Abdominal aortic aneurysm (AAA) is a multifactorial condition. The transforming growth factor beta (TGF-beta) pathway regulates vascular remodeling and mutations in its receptor genes, TGFBR1 and TGFBR2, cause syndromes with thoracic aortic aneurysm (TAA). The TGF-beta pathway may be involved in aneurysm development in general. We performed an association study by analyzing all the common genetic variants in TGFBR1 and TGFBR2 using tag single nucleotide polymorphisms (SNPs) in a Dutch AAA case-control population in a two-stage genotyping approach. In stage 1, analyzing 376 cases and 648 controls, three of the four TGFBR1 SNPs and nine of the 28 TGFBR2 SNPs had a P<0.07. Genotyping of these SNPs in an independent cohort of 360 cases and 376 controls in stage 2 confirmed association (P<0.05) for the same allele of one SNP in TGFBR1 and two SNPs in TGFBR2. Joint analysis of the 736 cases and 1024 controls showed statistically significant associations of these SNPs, which sustained after proper correction for multiple testing (TGFBR1 rs1626340 OR 1.32 95% CI 1.11-1.56 P=0.001 and TGFBR2 rs1036095 OR 1.32 95% CI 1.12-1.54 P=0.001 and rs4522809 OR 1.28 95% CI 1.12-1.46 P=0.0004). We conclude that genetic variations in TGFBR1 and TGFBR2 associate with AAA in the Dutch population. This suggests that AAA may develop partly by similar defects as TAA, which in the future may provide novel therapeutic options.
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Aneurisma de la Aorta Abdominal/genética , Polimorfismo de Nucleótido Simple , Proteínas Serina-Treonina Quinasas/genética , Receptores de Factores de Crecimiento Transformadores beta/genética , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/cirugía , Femenino , Frecuencia de los Genes , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Receptor Tipo I de Factor de Crecimiento Transformador beta , Receptor Tipo II de Factor de Crecimiento Transformador beta , Población Blanca/genéticaRESUMEN
Endovascular aneurysm repair (EVAR) represents one of the greatest advances in vascular surgery over the past 50 years. In contrast to conventional aneurysm repair, EVAR requires accurate preoperative imaging and stringent postoperative surveillance. Duplex ultrasound (DUS), transesophageal echocardiography, intravascular ultrasound, computed tomography (CT) and magnetic resonance (MR), each provide useful information for patient selection, choice of endograft type and surveillance. Today most interventionists and surgeons will rely on CT or MR to assess aortic morphology, evaluate access artery patency and locate side branch orifices. However, recent developments in cross-sectional imaging, including advanced image postprocessing, multi-modality image fusion and new contrast agents have resulted in improved spatial resolution for preoperative planning. Advanced reconstruction algorithms, like dynamic CTA and MRA, provide valuable information on dynamic changes in aneurysm morphology that might have an important impact on endograft selection. During follow-up, imaging of the graft and aneurysm is of utmost importance to identify patients in need of secondary intervention. This has led to rigorous follow-up protocols including duplex ultrasound and regular CT examinations. The use of these intense follow-up protocols has recently been questioned because of high radiation dose and the frequent use of nephrotoxic contrast agents. New imaging modalities like contrast enhanced DUS, dynamic MR and dual-source CT could reduce radiation dose and obviate the need for nephrotoxic contrast. Up-to-date knowledge of non-invasive vascular imaging and image processing is crucial for EVAR planning and is essential for the development of follow-up programs involving reduced risk of harmful side effects.
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Aneurisma de la Aorta Abdominal/diagnóstico , Implantación de Prótesis Vascular , Diagnóstico por Imagen , Selección de Paciente , Angiografía de Substracción Digital , Aneurisma de la Aorta Abdominal/cirugía , Aortografía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Diagnóstico por Imagen/efectos adversos , Diagnóstico por Imagen/métodos , Ecocardiografía Transesofágica , Humanos , Angiografía por Resonancia Magnética , Valor Predictivo de las Pruebas , Diseño de Prótesis , Radiografía Intervencional , Reoperación , Medición de Riesgo , Stents , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Ultrasonografía Doppler Dúplex , Ultrasonografía IntervencionalRESUMEN
OBJECTIVES: Endovascular techniques are an integral part of modern-day vascular surgery practice and training. Nevertheless, validated in vitro assessment tools for these skills are scarce. This study describes the development and pilot testing of the Simulator for Testing and Rating Endovascular Skills (STRESS machine). DESIGN: The design was kept straightforward and compact, without the need for contrast or fluoroscopy. A specific technical skill score was designed analogous to the Imperial College Evaluation of Procedural Skill (ICEPS), an assessment score for open surgical skill. This score was combined with an already validated global rating assessment to form the total score (TS). METHODS: A pilot study was carried out on 18 candidates of varying levels of expertise: novice, intermediate and expert, who were assessed by two independent observers to test inter-observer reliability. RESULTS: Inter-observer reliability was excellent, Cronbach's alpha coefficient of the TS was 0.94 (95% confidence interval: 0.84-0.97). A one-way analysis of variance (ANOVA) showed a significant difference between the novice and expert groups (p<0.001), between the novice and intermediate groups (p<0.01) and between the intermediate and expert groups (p<0.05). CONCLUSION: The STRESS machine, in combination with the specific technical skill score and global rating assessment, provides a reliable method of discriminating between the novice, intermediate and expert candidates with excellent inter-observer variability.
Asunto(s)
Cateterismo , Competencia Clínica , Simulación por Computador , Obstrucción de la Arteria Renal/terapia , Humanos , Proyectos Piloto , Reproducibilidad de los Resultados , Factores de TiempoRESUMEN
PURPOSE: To investigate the usefulness of greater saphenous vein preservation for future vascular reconstructions during femoro-popliteal bypass surgery. DESIGN: Post-hoc analysis of data acquired in a randomized multi-centre clinical trial comparing two different vascular prostheses (ClinicalTrials.gov ID: NCT 00523263). PATIENTS AND METHODS: The true frequency of ipsilateral saphenous vein use in subsequent femoro-popliteal and coronary bypass surgery was investigated through case-record analysis with a median follow-up of 60 months in 100 consecutive patients, that received a prosthetic femoro-popliteal bypass between 1996 and 2001. RESULTS: An ipsilateral secondary femoro-popliteal bypass was performed in 11 patients (11%) at a mean interval of 34 months (range 1-96). The ipsilateral saphenous vein was applied for these procedures in 8 cases (8%). The cumulative probability of receiving a subsequent bypass was 8% at 3 years and 10% at 5 years follow-up respectively. One patient (1%) underwent CABG at 8 years follow-up with the use of ipsilateral lower leg saphenous vein segments only. CONCLUSION: Preservation of the greater saphenous vein in supragenicular femoro-popliteal bypass surgery is not a valid argument for application of prosthetic material.
Asunto(s)
Implantación de Prótesis Vascular , Arteria Femoral/cirugía , Isquemia/cirugía , Arteria Poplítea/cirugía , Vena Safena/trasplante , Adulto , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria , Femenino , Humanos , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como Asunto , ReoperaciónAsunto(s)
Enfermedades de la Aorta/cirugía , Arteriopatías Oclusivas/cirugía , Infecciones Relacionadas con Prótesis/terapia , Infecciones por Pseudomonas/terapia , Adulto , Antibacterianos/uso terapéutico , Comorbilidad , Drenaje , Femenino , Humanos , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Infecciones Relacionadas con Prótesis/microbiología , Infecciones por Pseudomonas/diagnóstico por imagen , Infecciones por Pseudomonas/microbiología , Tomografía Computarizada por Rayos XRESUMEN
INTRODUCTION: The results of endovascular stent-grafts in the abdominal aorta and descending thoracic aorta have been encouraging. Expanding the use of thoracic stent-grafts in to the aortic arch has been associated with increasing numbers of complications. Recently isolated cases of stent-graft collapse have been reported. METHODS: This was a multi-centre European case series. Data was collected retrospectively on seven patients from five experienced endovascular centres with thoracic stent-graft collapse. RESULTS: Of the seven patients four were treated for traumatic aortic rupture. Six were male, median age 33 (range 17-54) years. During the ensuing 2 months all patients suffered stent-graft collapse. This was symptomatic in 3 patients and the rest were identified on CT. Endovascular management was possible in 6/7 patients using either a balloon expandable stent (n=6) or further stent-graft (n=1). Two patients had persistent type I endoleak despite treatment. Two of the 7 patients died, both of which presented with symptomatic thoracic stent-graft occlusion. Both deaths were a direct result of stent-graft collapse. CONCLUSIONS: Thoracic stent-graft collapse may be asymptomatic underscoring the importance of stent-graft surveillance. Endovascular management of collapse is possible in most cases using a large balloon expandable stent. Symptomatic collapse is associated with high morbidity and mortality.
Asunto(s)
Aorta Torácica/cirugía , Prótesis Vascular , Falla de Prótesis , Stents , Adolescente , Adulto , Aneurisma Falso/cirugía , Angioplastia de Balón , Enfermedades de la Aorta/cirugía , Rotura de la Aorta/cirugía , Fístula Esofágica/cirugía , Femenino , Oclusión de Injerto Vascular/terapia , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Estudios RetrospectivosRESUMEN
BACKGROUND: Patients with abdominal aortic aneurysm (AAA) can be treated by transfemoral endovascular intervention and by conventional open surgery. Level-one evidence of the safety and efficacy of one treatment mode over the other is only provided by a randomised controlled trial (RCT). Results reported by voluntary registries are considered less valid than data from RCTs. On the other hand the outcome of a RCT may not be generalisable to the common practice because of vigorous selection of patients and institutions. PURPOSE: The outcomes reported by the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial were compared with the results of the EURopean collaborators on Stent-graft techniques for AAA Repair (EUROSTAR) registry. METHODS: To obtain comparable study groups with regard to risk factors equal proportions of ASA I, II and III patients as observed in the endovascular arm of the DREAMtrial were selected at random from the EUROSTAR-registry. All patients had an aneurysm of at least 50mm. Only patients, who had been enrolled into the registry from 1999, were selected to avoid the influence of first generation endografts which are not longer in use. Patient characteristics and outcomes of endovascular AAA repair (EVAR) of EUROSTAR and DREAM-trial participants were compared. Differences in early findings between study groups were assessed by Chi-Square tests for discrete variables and by Wilcoxon rank sum tests for continuous variables. Follow-up variables were analysed by Kaplan-Meier and Cox proportional hazard models. RESULTS: Data of 177 patients of the DREAM trial with randomization to EVAR and 856 patients selected in the EUROSTAR-registry were compared. Baseline characteristics were comparable between the EUROSTAR-cohort and EVAR-arm of the DREAM-trial. The 36-month survival-rate was 87.6% for EVAR-arm in the DREAM-trial similar to the 86.8% found in this EUROSTAR-study population. The freedom of secondary procedures reached after 3 years 85.7%, and 86.9% in the DREAM and EUROSTAR-cohort, respectively. CONCLUSION: We found comparable characteristics and outcomes between patients of comparable risk class of the EUROSTAR-registry and the EVAR-cohort of the DREAM-trial. This demonstrates the following: first, the EUROSTAR-data provide reliable information, and further comparisons of registry data with patients treated by conventional AAA surgery may be justified. Secondly, the various outcomes of the randomised DREAM trial appear generalisable, as it agrees with observations in a broad common practice derived database.